<div class="row">
			<div  class="title">
		
				<div class="t1">今回ご購入頂いた商品をお選びください。</div>
				<div  class="t2"><img class ="td-icon" src="<?php echo base_url(); ?>assets/image/title2.png" ></div>
			</div>
			<!--<label class="desc" id="title1" for="Field1">応募ID(14ケタ)<img src="image/2_PC_キムタオル_入力_03.png" width="20" height="10"></img></label>-->
			<div class="fieldColumn" >
				<table>
					<tbody>
						<tr>
							<td width="50%"><input type="checkbox" name="q1[]" id="q1" class="i_buyNameItem" value="1"><label for="q1">キムワイプS-200</td>
							<td width="50%"><input type="checkbox" name="q1[]" id="i_buyNameItem2" class="i_buyNameItem" value="2"><label for="i_buyNameItem2">キムワイプM-150</td>
						</tr>
						<tr>
							<td><input type="checkbox" name="q1[]" id="i_buyNameItem3" class="i_buyNameItem" value="3"><label for="i_buyNameItem3">キムワイプL-100</td>
							<td><input type="checkbox" name="q1[]" id="i_buyNameItem4" class="i_buyNameItem" value="4"><label for="i_buyNameItem4">JKワイパー150-S</td>
							<td></td>
						</tr>
						<tr>
							<td><input type="checkbox" name="q1[]" id="i_buyNameItem5" class="i_buyNameItem" value="5"><label for="i_buyNameItem5">JKワイパー100-S	</td>
							<td><input type="checkbox" name="q1[]" id="i_buyNameItem6" class="i_buyNameItem" value="6"><label for="i_buyNameItem6">ケイドライ132-S</td>
						</tr>
						<tr>
							<td><input type="checkbox" name="q1[]" id="i_buyNameItem7" class="i_buyNameItem" value="7"><label for="i_buyNameItem7"> キムタオル4つ折り(茶色)</td>
							<td><input type="checkbox" name="q1[]" id="i_buyNameItem8" class="i_buyNameItem" value="8"><label for="i_buyNameItem8">キムタオルホワイト 4つ折り</td>
						</tr>
					</tbody>
				</table>

			</div>
</div>
<div class="row">
			<div  class="title">
				<div class="t1">月間購入量(上記8商品合計)をお選びください。</div>
				<div  class="t2"><img class ="td-icon" src="<?php echo base_url(); ?>assets/image/title2.png" ></div>
			</div>
			<!--<label class="desc" id="title1" for="Field1">応募ID(14ケタ)<img src="assets/image/2_PC_キムタオル_入力_03.png" width="20" height="10"></img></label>-->
			<div class="fieldColumn" >
					<table>
						<tbody>
							<tr>
								<td width="50%"><input type="radio" name="q2[]" id="i_buyQuantity1" class="i_buyQuantity" value="1"><label for="i_buyQuantity1">1～2ケース</label></td>
								<td width="50%"><input type="radio" name="q2[]" id="i_buyQuantity2" class="i_buyQuantity" value="2"><label for="i_buyQuantity2">3～4ケース</label></td>
							
							</tr>
							<tr>
								<td ><input type="radio" name="q2[]" id="i_buyQuantity3" class="i_buyQuantity" value="3"><label for="i_buyQuantity3">5～9ケース</label>　</td>
								<td><input type="radio" name="q2[]" id="i_buyQuantity4" class="i_buyQuantity" value="4"><label for="i_buyQuantity4">10～29ケース</label></td>
							</tr>
							<tr>
								<td><input type="radio" name="q2[]" id="i_buyQuantity5" class="i_buyQuantity" value="5"><label for="i_buyQuantity5">30ケース以上</label></td>
								<td></td>
							</tr>
						</tbody>
						
					</table>
		
			</div>
</div>
<div class="row">
			<div  class="title">
				<table>
					<tbody>
						<tr>
							<th style="font-weight:900; font-style:bold;padding:10px;">業種をお教えください。</th>
								<th width="50"><img class ="td-icon" src="<?php echo base_url(); ?>assets/image/title2.png" ></th>
						</tr>
					</tbody>
				</table>
			</div>
			<!--<label class="desc" id="title1" for="Field1">応募ID(14ケタ)<img src="assets/image/2_PC_キムタオル_入力_03.png" width="20" height="10"></img></label>-->
			<div class="fieldColumn" >
					<table>
						<tbody>
							<tr>
								<td width="50%"><input type="radio" name="q31[]" id="i_workType_0" class="i_workType" value="1"><label for="i_workType_0">官公庁研究機関</label></td>
								<td width="50%"><input type="radio" name="q31[]" id="i_workType_1" class="i_workType" value="2"><label for="i_workType_1">大学</label> </td>
								
							</tr>
							<tr>
								<td ><input type="radio" name="q31[]" id="i_workType_2" class="i_workType" value="3"><label for="i_workType_2">各種学校</label></td>
								<td>	<input type="radio" name="q31[]" id="i_workType_3" class="i_workType" value="4"><label for="i_workType_3">民間企業研究機関</label></td>
							</tr>
							<tr>
								<td><input type="radio" name="q31[]" id="i_workType_4" class="i_workType" value="5"><label for="i_workType_4">工場</label> </td>
								<td><input type="radio" name="q31[]" id="i_workType_5" class="i_workType" value="6"><label for="i_workType_5"> 病院 </label></td>
							</tr>
							<tr>
								<td colspan="2"><input type="radio" name="q31[]" id="i_workType_6" class="i_workType" value="99"><label for="i_workType_6">その他</label><input type="text" name="q31text" id ="q31text"></td>
							</tr>
						</tbody>
					</table>
					
 						
						
 					
 						
						
 						
			</div>
</div>
<div class="row">
			<div  class="title">
				<table>
					<tbody>
						<tr>
							<th style="font-weight:900; font-style:bold;padding:10px;">使用用途をお教えください。<br />
							(複数回答可)</th>
								<th width="50"><img class ="td-icon" src="<?php echo base_url(); ?>assets/image/title2.png" ></th>
						</tr>
					</tbody>
				</table>
			</div>
			<!--<label class="desc" id="title1" for="Field1">応募ID(14ケタ)<img src="image/2_PC_キムタオル_入力_03.png" width="20" height="10"></img></label>-->
			<div class="fieldColumn" >
					<table>
						<tbody>
							<tr>
								<td width="50%"><input type="checkbox" id="i_useComment_0" name="q41[]" class="useComment" value="1"><label for="i_useComment_0">作業台のふきとり</label></td>
								<td width="50%">	<input type="checkbox" id="i_useComment_1" name="q41[]" class="useComment" value="2"><label for="i_useComment_1">実験器具のふきとり</label></td>
							</tr>
							<tr>
								<td><input type="checkbox" id="i_useComment_2" name="q41[]" class="useComment" value="3"><label for="i_useComment_2">油のふきとり</label></td>
								<td><input type="checkbox" id="i_useComment_3" name="q41[]" class="useComment" value="4"><label for="i_useComment_3">薬液のふきとり</label></td>
							</tr>
							<tr>
								<td><input type="checkbox" id="i_useComment_4" name="q41[]" class="useComment" value="5"><label for="i_useComment_4">水のふきとり</label></td>
								<td><input type="checkbox" id="i_useComment_5" name="q41[]" class="useComment" value="6"><label for="i_useComment_5">機材・器具部品のふきあげ</label></td>
							</tr>
							<tr>
								<td><input type="checkbox" id="i_useComment_6" name="q41[]" class="useComment" value="7"><label for="i_useComment_6">傷つきやすい物のふきあげ</label></td>
								<td><input type="checkbox" id="i_useComment_7" name="q41[]" class="useComment" value="8"><label for="i_useComment_7">レンズのふきあげ</label></td>
							</tr>
							<tr>
								<td><input type="checkbox" id="i_useComment_8" name="q41[]" class="useComment" value="9"><label for="i_useComment_8">検査工程</label></td>
								<td><input type="checkbox" id="i_useComment_9" name="q41[]" class="useComment" value="10"><label for="i_useComment_9">布・ウエスの代用</label></td>
							</tr>
						</tbody>
					</table>
			</div>
</div>

